CHAPTER 1451. ACCESS TO CERTAIN PRACTITIONERS AND FACILITIES
INSURANCE CODE
TITLE 8. HEALTH INSURANCE AND OTHER HEALTH COVERAGES
SUBTITLE F. PHYSICIANS AND HEALTH CARE PROVIDERS
CHAPTER 1451. ACCESS TO CERTAIN PRACTITIONERS AND FACILITIES
SUBCHAPTER A. GENERAL PROVISIONS
Sec. 1451.001. DEFINITIONS; HEALTH CARE PRACTITIONERS. In this
chapter:
(1) "Acupuncturist" means an individual licensed to practice
acupuncture by the Texas State Board of Medical Examiners.
(2) "Advanced practice nurse" means an individual licensed by
the Texas Board of Nursing as a registered nurse and recognized
by that board as an advanced practice nurse.
(3) "Audiologist" means an individual licensed to practice
audiology by the State Board of Examiners for Speech-Language
Pathology and Audiology.
(4) "Chemical dependency counselor" means an individual licensed
by the Texas Commission on Alcohol and Drug Abuse.
(5) "Chiropractor" means an individual licensed by the Texas
Board of Chiropractic Examiners.
(6) "Dentist" means an individual licensed to practice dentistry
by the State Board of Dental Examiners.
(7) "Dietitian" means an individual licensed by the Texas State
Board of Examiners of Dietitians.
(8) "Hearing instrument fitter and dispenser" means an
individual licensed by the State Committee of Examiners in the
Fitting and Dispensing of Hearing Instruments.
(9) "Licensed clinical social worker" means an individual
licensed by the Texas State Board of Social Worker Examiners as a
licensed clinical social worker.
(10) "Licensed professional counselor" means an individual
licensed by the Texas State Board of Examiners of Professional
Counselors.
(11) "Marriage and family therapist" means an individual
licensed by the Texas State Board of Examiners of Marriage and
Family Therapists.
(12) "Occupational therapist" means an individual licensed as an
occupational therapist by the Texas Board of Occupational Therapy
Examiners.
(13) "Optometrist" means an individual licensed to practice
optometry by the Texas Optometry Board.
(14) "Physical therapist" means an individual licensed as a
physical therapist by the Texas Board of Physical Therapy
Examiners.
(15) "Physician" means an individual licensed to practice
medicine by the Texas State Board of Medical Examiners. The term
includes a doctor of osteopathic medicine.
(16) "Physician assistant" means an individual licensed by the
Texas State Board of Physician Assistant Examiners.
(17) "Podiatrist" means an individual licensed to practice
podiatry by the Texas State Board of Podiatric Medical Examiners.
(18) "Psychological associate" means an individual licensed as a
psychological associate by the Texas State Board of Examiners of
Psychologists who practices solely under the supervision of a
licensed psychologist.
(19) "Psychologist" means an individual licensed as a
psychologist by the Texas State Board of Examiners of
Psychologists.
(20) "Speech-language pathologist" means an individual licensed
to practice speech-language pathology by the State Board of
Examiners for Speech-Language Pathology and Audiology.
(21) "Surgical assistant" means an individual licensed as a
surgical assistant by the Texas State Board of Medical Examiners.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.041(a), eff. September 1, 2005.
Acts 2007, 80th Leg., R.S., Ch.
889, Sec. 71, eff. September 1, 2007.
SUBCHAPTER B. DESIGNATION OF PRACTITIONERS UNDER ACCIDENT AND
HEALTH INSURANCE POLICY
Sec. 1451.051. APPLICABILITY OF SUBCHAPTER. (a) This
subchapter applies to an accident and health insurance policy,
including an individual, blanket, or group policy.
(b) This subchapter applies to an accident and health insurance
policy issued by a stipulated premium company subject to Chapter
884.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.052. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.
The provisions of Chapter 1201, including provisions relating to
the applicability, purpose, and enforcement of that chapter, the
construction of policies under that chapter, rulemaking under
that chapter, and definitions of terms applicable in that
chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.053. PRACTITIONER DESIGNATION. (a) An accident and
health insurance policy may not make a benefit contingent on
treatment or examination by one or more particular health care
practitioners listed in Section 1451.001 unless the policy
contains a provision that designates the practitioners whom the
insurer will and will not recognize.
(b) The insurer may include the provision anywhere in the policy
or in an endorsement attached to the policy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.054. TERMS USED TO DESIGNATE HEALTH CARE
PRACTITIONERS. A provision of an accident and health insurance
policy that designates the health care practitioners whom the
insurer will and will not recognize must use the terms defined by
Section 1451.001 with the meanings assigned by that section.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER C. SELECTION OF PRACTITIONERS
Sec. 1451.101. DEFINITIONS. In this subchapter:
(1) "Health insurance policy" means a policy, contract, or
agreement described by Section 1451.102.
(2) "Insured" means an individual who is issued, is a party to,
or is a beneficiary under a health insurance policy.
(3) "Insurer" means an insurer, association, or organization
described by Section 1451.102.
(4) "Nurse first assistant" has the meaning assigned by Section
301.1525, Occupations Code.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.102. APPLICABILITY OF SUBCHAPTER. Except as provided
by this subchapter, this subchapter applies only to an
individual, group, blanket, or franchise insurance policy,
insurance agreement, or group hospital service contract that
provides health benefits, accident benefits, or health and
accident benefits for medical or surgical expenses incurred as a
result of an accident or sickness and that is delivered, issued
for delivery, or renewed in this state by any incorporated or
unincorporated insurance company, association, or organization,
including:
(1) a fraternal benefit society operating under Chapter 885;
(2) a general casualty company operating under Chapter 861;
(3) a life, health, and accident insurance company operating
under Chapter 841 or 982;
(4) a Lloyd's plan operating under Chapter 941;
(5) a local mutual aid association operating under Chapter 886;
(6) a mutual insurance company writing insurance other than life
insurance operating under Chapter 883;
(7) a mutual life insurance company operating under Chapter 882;
(8) a reciprocal exchange operating under Chapter 942;
(9) a statewide mutual assessment company, mutual assessment
company, or mutual assessment life, health, and accident
association operating under Chapter 881 or 887; and
(10) a stipulated premium company operating under Chapter 884.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.103. CONFLICTING PROVISIONS VOID. (a) A provision of
a health insurance policy that conflicts with this subchapter is
void to the extent of the conflict.
(b) The presence in a health insurance policy of a provision
void under Subsection (a) does not affect the validity of other
policy provisions.
(c) An insurer shall bring each approved policy form that
contains a provision that conflicts with this subchapter into
compliance with this subchapter by use of:
(1) a rider or endorsement approved by the commissioner; or
(2) a new or revised policy form approved by the commissioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.104. NONDISCRIMINATORY PAYMENT OR REIMBURSEMENT;
EXCEPTION. (a) An insurer may not classify, differentiate, or
discriminate between scheduled services or procedures provided by
a health care practitioner selected under this subchapter and
performed in the scope of that practitioner's license and the
same services or procedures provided by another type of health
care practitioner whose services or procedures are covered by a
health insurance policy, in regard to:
(1) the payment schedule or payment provisions of the policy; or
(2) the amount or manner of payment or reimbursement under the
policy.
(b) An insurer may not deny payment or reimbursement for
services or procedures in accordance with the policy payment
schedule or payment provisions solely because the services or
procedures were performed by a health care practitioner selected
under this subchapter.
(c) Notwithstanding Subsection (a), a health insurance policy
may provide for a different amount of payment or reimbursement
for scheduled services or procedures performed by an advanced
practice nurse, nurse first assistant, licensed surgical
assistant, or physician assistant if the methodology used to
compute the amount is the same as the methodology used to compute
the amount of payment or reimbursement when the services or
procedures are provided by a physician.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.105. SELECTION OF ACUPUNCTURIST. An insured may
select an acupuncturist to provide the services or procedures
scheduled in the health insurance policy that are within the
scope of the acupuncturist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.106. SELECTION OF ADVANCED PRACTICE NURSE. An insured
may select an advanced practice nurse to provide the services
scheduled in the health insurance policy that are within the
scope of the nurse's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.107. SELECTION OF AUDIOLOGIST. An insured may select
an audiologist to measure hearing to determine the presence or
extent of the insured's hearing loss or provide aural
rehabilitation services to the insured if the insured has a
hearing loss and the services or procedures are scheduled in the
health insurance policy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.108. SELECTION OF CHEMICAL DEPENDENCY COUNSELOR. An
insured may select a chemical dependency counselor to provide
services or procedures scheduled in the health insurance policy
that are within the scope of the counselor's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.109. SELECTION OF CHIROPRACTOR. An insured may select
a chiropractor to provide the medical or surgical services or
procedures scheduled in the health insurance policy that are
within the scope of the chiropractor's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.110. SELECTION OF DENTIST. An insured may select a
dentist to provide the medical or surgical services or procedures
scheduled in the health insurance policy that are within the
scope of the dentist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.111. SELECTION OF DIETITIAN. An insured may select a
licensed dietitian or a provisionally licensed dietitian acting
under the supervision of a licensed dietitian to provide the
services scheduled in the health insurance policy that are within
the scope of the dietitian's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.112. SELECTION OF HEARING INSTRUMENT FITTER AND
DISPENSER. An insured may select a hearing instrument fitter and
dispenser to provide the services or procedures scheduled in the
health insurance policy that are within the scope of the license
of the fitter and dispenser.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.113. SELECTION OF LICENSED CLINICAL SOCIAL WORKER.
An insured may select a licensed clinical social worker to
provide the services or procedures scheduled in the health
insurance policy that:
(1) are within the scope of the social worker's license,
including the provision of direct, diagnostic, preventive, or
clinical services to individuals, families, and groups whose
functioning is threatened or affected by social or psychological
stress or health impairment; and
(2) are specified as services under the terms of the health
insurance policy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.042(a), eff. September 1, 2005.
Sec. 1451.114. SELECTION OF LICENSED PROFESSIONAL COUNSELOR.
An insured may select a licensed professional counselor to
provide the services scheduled in the health insurance policy
that are within the scope of the counselor's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
221, Sec. 1, eff. September 1, 2009.
Sec. 1451.115. SELECTION OF SURGICAL ASSISTANT. An insured may
select a surgical assistant to provide the services or procedures
scheduled in the health insurance policy that are within the
scope of the assistant's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.116. SELECTION OF MARRIAGE AND FAMILY THERAPIST. An
insured may select a marriage and family therapist to provide the
services scheduled in the health insurance policy that are within
the scope of the therapist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2009, 81st Leg., R.S., Ch.
221, Sec. 2, eff. September 1, 2009.
Sec. 1451.117. SELECTION OF NURSE FIRST ASSISTANT. An insured
may select a nurse first assistant to provide the services
scheduled in the health insurance policy that:
(1) are within the scope of the nurse's license; and
(2) are requested by the physician whom the nurse is assisting.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.118. SELECTION OF OCCUPATIONAL THERAPIST. An insured
may select an occupational therapist to provide the services
scheduled in the health insurance policy that are within the
scope of the therapist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.119. SELECTION OF OPTOMETRIST. An insured may select
an optometrist to provide the services or procedures scheduled in
the health insurance policy that are within the scope of the
optometrist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.120. SELECTION OF PHYSICAL THERAPIST. An insured may
select a physical therapist to provide the services scheduled in
the health insurance policy that are within the scope of the
therapist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.121. SELECTION OF PHYSICIAN ASSISTANT. An insured may
select a physician assistant to provide the services scheduled in
the health insurance policy that are within the scope of the
assistant's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.122. SELECTION OF PODIATRIST. An insured may select a
podiatrist to provide the medical or surgical services or
procedures scheduled in the health insurance policy that are
within the scope of the podiatrist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.123. SELECTION OF PSYCHOLOGICAL ASSOCIATE. An insured
may select a psychological associate to provide the services
scheduled in the health insurance policy that are within the
scope of the associate's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.124. SELECTION OF PSYCHOLOGIST. An insured may select
a psychologist to provide the services or procedures scheduled in
the health insurance policy that are within the scope of the
psychologist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.125. SELECTION OF SPEECH-LANGUAGE PATHOLOGIST. An
insured may select a speech-language pathologist to evaluate
speech or language, provide habilitative or rehabilitative
services to restore speech or language loss, or correct a speech
or language impairment if the services or procedures are
scheduled in the health insurance policy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.126. REIMBURSEMENT FOR PHYSICAL MODALITIES AND
PROCEDURES BY HEALTH INSURER, ADMINISTRATOR, HEALTH MAINTENANCE
ORGANIZATION, OR PREFERRED PROVIDER BENEFIT PLAN ISSUER. (a) A
health insurer or licensed third-party administrator may not deny
reimbursement to a health care practitioner for the provision of
covered services of physical modalities and procedures that are
within the scope of the practitioner's practice if the services
are performed in strict compliance with:
(1) laws and rules related to that practitioner's license; and
(2) the terms of the insurance policy or other coverage
agreement.
(b) A health maintenance organization or preferred provider
benefit plan issuer may not deny reimbursement to a participating
health care practitioner for services provided under a coverage
agreement solely because of the type of practitioner providing
the services if the services are performed in strict compliance
with:
(1) laws and rules related to that practitioner's license; and
(2) the terms of the insurance policy or other coverage
agreement.
(c) This section may not be construed to circumvent any
contractual provider network agreement between a health insurer
or third-party administrator and a licensed health care
practitioner.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.127. DUTY OF PERSON ARRANGING PROVIDER CONTRACTS FOR
HEALTH INSURER OR HEALTH MAINTENANCE ORGANIZATION. (a) A person
who arranges contracts with providers on behalf of a health
maintenance organization or health insurer shall comply with laws
related to the duties of the organization or insurer to notify
and consider providers for those contracts.
(b) A violation of this section:
(1) is an unlawful practice under Section 15.05, Business &
Commerce Code; and
(2) constitutes restraint of trade.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER D. ACCESS TO OPTOMETRISTS AND OPHTHALMOLOGISTS USED
UNDER MANAGED CARE PLAN
Sec. 1451.151. DEFINITIONS. In this subchapter:
(1) "Managed care plan" means a plan under which a health
maintenance organization, preferred provider benefit plan issuer,
or other organization provides or arranges for health care
benefits to plan participants and requires or encourages plan
participants to use health care practitioners the plan
designates.
(2) "Ophthalmologist" means a physician who specializes in
ophthalmology.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.152. APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER.
(a) This subchapter applies only to a managed care plan that
provides or arranges for benefits for vision or medical eye care
services or procedures that are within the scope of an
optometrist's or therapeutic optometrist's license.
(b) This subchapter does not require a managed care plan to
provide vision or medical eye care services or procedures.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.153. USE OF OPTOMETRIST, THERAPEUTIC OPTOMETRIST, OR
OPHTHALMOLOGIST. (a) A managed care plan may not:
(1) discriminate against a health care practitioner because the
practitioner is an optometrist, therapeutic optometrist, or
ophthalmologist;
(2) restrict or discourage a plan participant from obtaining
covered vision or medical eye care services or procedures from a
participating optometrist, therapeutic optometrist, or
ophthalmologist solely because the practitioner is an
optometrist, therapeutic optometrist, or ophthalmologist;
(3) exclude an optometrist, therapeutic optometrist, or
ophthalmologist as a participating practitioner in the plan
because the optometrist, therapeutic optometrist, or
ophthalmologist does not have medical staff privileges at a
hospital or at a particular hospital; or
(4) exclude an optometrist, therapeutic optometrist, or
ophthalmologist as a participating practitioner in the plan
because the services or procedures provided by the optometrist,
therapeutic optometrist, or ophthalmologist may be provided by
another type of health care practitioner.
(b) A managed care plan shall:
(1) include optometrists, therapeutic optometrists, and
ophthalmologists as participating health care practitioners in
the plan; and
(2) include the name of a participating optometrist, therapeutic
optometrist, or ophthalmologist in any list of participating
health care practitioners and give equal prominence to each name.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Amended by:
Acts 2005, 79th Leg., Ch.
728, Sec. 11.043, eff. September 1, 2005.
Sec. 1451.154. PARTICIPATION OF THERAPEUTIC OPTOMETRIST. (a)
In this section:
(1) "Medical panel" means the health care practitioners who are
listed as participating providers in a managed care plan or who a
patient seeking diagnosis or treatment of a medical disease,
disorder, or condition is encouraged or required to use under a
managed care plan.
(2) "Vision panel" means the optometrists, therapeutic
optometrists, and ophthalmologists who are listed as
participating providers for routine eye examinations under a
managed care plan or who a patient seeking a routine eye
examination is encouraged or required to use under a managed care
plan.
(b) A managed care plan must allow a therapeutic optometrist who
is on one or more of the plan's vision panels to be a fully
participating provider on the plan's medical panels to the full
extent of the therapeutic optometrist's license to practice
therapeutic optometry.
(c) A therapeutic optometrist who is included in a managed care
plan's medical panels under Subsection (b) must:
(1) abide by the terms and conditions of the managed care plan;
(2) satisfy the managed care plan's credentialing standards for
therapeutic optometrists;
(3) provide proof that the Texas Optometry Board considers the
therapeutic optometrist's license to practice therapeutic
optometry to be in good standing; and
(4) comply with the requirements of the Controlled Substances
Registration Program operated by the Department of Public Safety.
(d) A managed care plan may charge a participating therapeutic
optometrist:
(1) any reasonable credentialing costs associated with the
therapeutic optometrist's being included in the managed care
plan's medical panel; and
(2) a one-time administrative fee not to exceed $200 for
expenses incurred in adding the therapeutic optometrist to the
managed care plan's medical panel.
Added by Acts 2005, 79th Leg., Ch.
728, Sec. 11.044(a), eff. September 1, 2005.
SUBCHAPTER E. DENTAL CARE BENEFITS IN HEALTH INSURANCE POLICIES
OR EMPLOYEE BENEFIT PLANS
Sec. 1451.201. DEFINITIONS. In this subchapter:
(1) "Dental care service" means a service provided to a person
to prevent, alleviate, cure, or heal a human dental illness or
injury.
(2) "Employee benefit plan" means a plan, fund, or program
established or maintained by an employer or employee
organization.
(3) "Health insurance policy" means any individual, group,
blanket, or franchise insurance policy, insurance agreement, or
group hospital service contract.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.202. APPLICABILITY AND CONSTRUCTION OF SUBCHAPTER.
(a) This subchapter applies only to an employee benefit plan or
health insurance policy delivered, issued for delivery, renewed,
or contracted for in this state to the extent that:
(1) the employee benefit plan is established or maintained to
provide dental care services, through insurance or otherwise, for
the plan's participants or the beneficiaries of the plan's
participants; or
(2) the health insurance policy provides benefits for dental
care services.
(b) This subchapter does not apply to a health maintenance
organization governed by Chapter 843.
(c) The exemptions and exceptions of Sections 881.002 and
881.004 and Article 21.41 do not apply to this subchapter.
(d) This subchapter does not require an employee benefit plan or
health insurance policy to provide any type of benefits for
dental care expenses.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.203. CONFLICTING PROVISIONS. A provision of an
employee benefit plan or health insurance policy that conflicts
with this subchapter is void to the extent of the conflict.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.204. CERTAIN CONDUCT PERMITTED. (a) Notwithstanding
any other provision of this subchapter, a dentist may contract
directly with a patient to provide dental care services to the
patient as authorized by law.
(b) Notwithstanding any other provision of this subchapter, a
person providing a health insurance policy or employee benefit
plan or an employer or an employee organization may:
(1) make information available to its insureds, beneficiaries,
participants, employees, or members regarding dental care
services through the distribution of factually accurate
information about dental care services and the rates, fees,
locations, and hours for the services if the information is
distributed on the request of a dentist;
(2) establish an administrative mechanism to facilitate payments
for dental care services from an insured, beneficiary,
participant, employee, or member to a dentist chosen by the
insured, beneficiary, participant, employee, or member; or
(3) nondiscriminatorily pay or reimburse its insured,
beneficiary, participant, employee, or member for the cost of
dental care services provided by a dentist chosen by the insured,
beneficiary, participant, employee, or member.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.205. DISCLOSURE OF BENEFIT TERMS. An employee benefit
plan or health insurance policy shall:
(1) if applicable, disclose that the benefit for dental care
services offered is limited to the least costly treatment; and
(2) specify in dollars and cents the amount of the payment or
reimbursement to be provided for dental care services or define
and explain the standard on which payment of benefits or
reimbursement for the cost of dental care services is based, such
as:
(A) "usual and customary" fees;
(B) "reasonable and customary" fees;
(C) "usual, customary, and reasonable" fees; or
(D) words of similar meaning.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.206. PAYMENT OR REIMBURSEMENT OF DENTIST. (a) The
employee benefit plan or health insurance policy shall provide:
(1) that payment or reimbursement for a noncontracting provider
dentist shall be the same as payment or reimbursement for a
contracting provider dentist; and
(2) that the party to or beneficiary of the plan or policy may
assign the right to payment or reimbursement to the dentist who
provides the dental care services.
(b) Notwithstanding Subsection (a)(1), the employee benefit plan
or health insurance policy is not required to make payment or
reimbursement in an amount greater than:
(1) the amount specified in the plan or policy; or
(2) the fee the providing dentist charges for the dental care
services provided.
(c) If the right to payment or reimbursement is assigned as
provided by Subsection (a)(2):
(1) payment or reimbursement shall be made directly to the
designated dentist; and
(2) direct payment to the designated dentist discharges the
payor's obligation.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.207. PROHIBITED CONDUCT. (a) An employee benefit
plan or health insurance policy may not:
(1) interfere with or prevent an individual who is a party to or
beneficiary of the plan or policy from selecting a dentist of the
individual's choice to provide a dental care service the plan or
policy offers if the dentist selected is licensed in this state
to provide the service;
(2) deny a dentist the right to participate as a contracting
provider under the plan or policy if the dentist is licensed to
provide the dental care services the plan or policy offers;
(3) authorize a person to regulate, interfere with, or intervene
in the provision of dental care services a dentist provides a
patient, including diagnosis, if the dentist practices within the
scope of the dentist's license; or
(4) require a dentist to make or obtain a dental x-ray or other
diagnostic aid in providing dental care services.
(b) Subsection (a)(4) does not prohibit a request for an
existing dental x-ray or other existing diagnostic aid for a
determination of benefits payable under an employee benefit plan
or health insurance policy.
(c) This section does not prohibit the predetermination of
benefits for dental care expenses before the attending dentist
provides treatment.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER F. ACCESS TO OBSTETRICAL OR GYNECOLOGICAL CARE
Sec. 1451.251. DEFINITION. In this subchapter, "enrollee" means
an individual enrolled in a health benefit plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.252. APPLICABILITY OF SUBCHAPTER. This subchapter
applies only to a health benefit plan that requires an enrollee
to obtain certain specialty health care services through a
referral made by a primary care physician or other gatekeeper and
that:
(1) provides benefits for medical or surgical expenses incurred
as a result of a health condition, accident, or sickness,
including:
(A) an individual, group, blanket, or franchise insurance policy
or insurance agreement, a group hospital service contract, or an
individual or group evidence of coverage that is offered by:
(i) an insurance company;
(ii) a group hospital service corporation operating under
Chapter 842;
(iii) a fraternal benefit society operating under Chapter 885;
(iv) a stipulated premium company operating under Chapter 884;
or
(v) a health maintenance organization operating under Chapter
843; and
(B) to the extent permitted by the Employee Retirement Income
Security Act of 1974 (29 U.S.C. Section 1001 et seq.), a health
benefit plan that is offered by:
(i) a multiple employer welfare arrangement as defined by
Section 3 of that Act; or
(ii) another analogous benefit arrangement;
(2) is offered by:
(A) an approved nonprofit health corporation that holds a
certificate of authority under Chapter 844; or
(B) an entity that is not authorized under this code or another
insurance law of this state that contracts directly for health
care services on a risk-sharing basis, including a capitation
basis; or
(3) provides health and accident coverage through a risk pool
created under Chapter 172, Local Government Code, notwithstanding
Section 172.014, Local Government Code, or any other law.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.253. EXCEPTION. This subchapter does not apply to:
(1) a plan that provides coverage:
(A) only for a specified disease;
(B) only for accidental death or dismemberment;
(C) for wages or payments instead of wages for a period during
which an employee is absent from work because of sickness or
injury; or
(D) as a supplement to a liability insurance policy;
(2) a small employer health benefit plan written under Chapter
1501;
(3) a Medicare supplemental policy as defined by Section
1882(g)(1), Social Security Act (42 U.S.C. Section 1395ss);
(4) a workers' compensation insurance policy;
(5) medical payment insurance coverage provided under a motor
vehicle insurance policy;
(6) a long-term care insurance policy, including a nursing home
fixed indemnity policy, unless the commissioner determines that
the policy provides benefit coverage so comprehensive that the
policy is a health benefit plan as described by Section 1451.252;
or
(7) any health benefit plan that does not provide:
(A) benefits related to pregnancy; or
(B) well-woman care benefits.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.254. RULES. The commissioner shall adopt rules
necessary to implement this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.255. RIGHT OF FEMALE ENROLLEE TO SELECT OBSTETRICIAN
OR GYNECOLOGIST. (a) Except as provided by Subsection (b), a
health benefit plan shall permit a female enrollee to select, in
addition to a primary care physician, an obstetrician or
gynecologist to provide the enrollee with health care services
that are within the scope of the professional specialty practice
of a properly credentialed obstetrician or gynecologist.
(b) A health benefit plan may limit an enrollee's self-referral
under Subsection (a) to only one participating obstetrician or
gynecologist to provide both gynecological and obstetrical care
to the enrollee. This subsection does not affect the right of an
enrollee to select the physician who provides that care.
(c) This section does not preclude an enrollee from selecting a
qualified physician, including a family physician or internal
medicine physician, to provide the enrollee with health care
services described by Subsection (a).
(d) This section does not affect the authority of a health
benefit plan issuer to establish selection criteria regarding
other physicians who provide services under the plan.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.256. DIRECT ACCESS TO SERVICES OF OBSTETRICIAN OR
GYNECOLOGIST. (a) In this section, "health care services"
includes:
(1) one well-woman examination each year;
(2) care related to pregnancy;
(3) care for any active gynecological condition; and
(4) diagnosis, treatment, and referral for any disease or
condition that is within the scope of the professional specialty
practice of a properly credentialed obstetrician or gynecologist.
(b) In addition to other benefits authorized under the health
benefit plan, a health benefit plan shall permit an enrollee who
selects an obstetrician or gynecologist under Section 1451.255 to
have direct access to the health care services of that selected
physician without:
(1) a referral from the enrollee's primary care physician; or
(2) prior authorization or precertification from the plan
issuer.
(c) A health benefit plan may not impose a copayment or
deductible for direct access to health care services as required
by this section unless the same copayment or deductible is
imposed for access to other health care services provided under
the plan.
(d) This section does not affect the authority of a health
benefit plan issuer to require an obstetrician or gynecologist
selected by an enrollee under Section 1451.255 to forward
information concerning the medical care of the enrollee to the
enrollee's primary care physician.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.257. AVAILABILITY OF PROVIDERS. To ensure access to
services that are within the scope of the professional specialty
practice of a properly credentialed obstetrician or gynecologist,
a health benefit plan shall include in the classification of
persons authorized to provide medical services under the plan a
sufficient number of properly credentialed obstetricians and
gynecologists.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.258. NOTICE OF AVAILABLE PROVIDERS. (a) A health
benefit plan issuer shall provide to each person covered under
the plan a timely written notice of the choices of the types of
physician providers available for the direct access required
under this subchapter.
(b) The notice must be stated in clear and accurate language.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.259. LIMITS ON PHYSICIAN SANCTIONS. (a) A health
benefit plan may not sanction or terminate a primary care
physician because of female enrollees' access to participating
obstetricians and gynecologists under this subchapter.
(b) A health benefit plan may not impose a financial or other
penalty on an obstetrician or gynecologist selected under Section
1451.255, or on the enrollee who selected the physician, because
the selected physician failed to provide to the enrollee's
primary care physician information concerning the medical care of
the enrollee if the selected physician made a reasonable good
faith effort to forward the information.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.260. ADMINISTRATIVE PENALTY. An entity that operates
a health benefit plan in violation of this subchapter is subject
to an administrative penalty as provided by Chapter 84.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER G. ACCESS TO DIETITIAN SERVICES
Sec. 1451.301. APPLICABILITY OF GENERAL PROVISIONS OF OTHER LAW.
The provisions of Chapter 1201, including provisions relating to
the applicability, purpose, and enforcement of that chapter, the
construction of policies under that chapter, rulemaking under
that chapter, and definitions of terms applicable in that
chapter, apply to this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.302. DIETITIAN SERVICES. An individual or group
accident and health insurance policy delivered or issued for
delivery in this state may not:
(1) exclude or deny coverage for services performed by:
(A) a dietitian; or
(B) a provisionally licensed dietitian acting under the
supervision of a dietitian; or
(2) refuse payment or reimbursement for charges for services
described by Subdivision (1) if the services:
(A) are in the scope of the dietitian's license;
(B) are related to an injury or illness the policy covers if the
services are scheduled in the policy; and
(C) are provided under a professional recommendation of a
physician whose treatment or examination for the injury or
illness would be covered by the policy and would be payable or
reimbursable under the policy.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER H. DISABILITY CERTIFIED BY PODIATRIST
Sec. 1451.351. LOSS OF INCOME BENEFITS FOR DISABILITY TREATABLE
BY PODIATRIST. (a) This section applies only to an insurance
policy delivered, issued for delivery, or renewed in this state
that provides benefits covering loss of income as a result of an
acute temporary disability caused by sickness or injury.
(b) An insurance policy may not deny payment of benefits
described by Subsection (a) solely because the disability is
certified or attested to by a podiatrist if the disability is
caused by a sickness or injury that may be treated within the
scope of the podiatrist's license.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
SUBCHAPTER I. USE OF OSTEOPATHIC HOSPITAL
Sec. 1451.401. CONTRACT WITH OSTEOPATHIC HOSPITAL. A health
maintenance organization or preferred provider benefit plan
issuer that contracts with a hospital to provide services to
covered individuals may not refuse to contract with an
osteopathic hospital solely because the hospital is an
osteopathic hospital.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.402. SERVICES AT OSTEOPATHIC HOSPITAL. A health
maintenance organization or preferred provider benefit plan
issuer that provides benefits for inpatient or outpatient
services provided by an allopathic hospital shall seek to provide
benefits for similar services provided by an osteopathic hospital
if there is an osteopathic hospital within the service area of
the health maintenance organization or preferred provider benefit
plan issuer that will provide the services at a substantially
similar cost.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.403. REQUEST FOR ACTION OF COMMISSIONER. An aggrieved
party may request that the commissioner conduct an investigation,
review, hearing, or other proceeding to determine compliance with
this subchapter.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.
Sec. 1451.404. ENFORCEMENT. The commissioner shall take all
reasonable actions to ensure compliance with this subchapter,
including issuing orders and assessing penalties.
Added by Acts 2003, 78th Leg., ch. 1274, Sec. 3, eff. April 1,
2005.